You could be forgiven for thinking that Wednesday’s budget didn’t say much about health – other than that headline-grabbing sugar levy. And following the frontloaded increase in NHS funding set out in November’s Spending Review, you might think that the health service really isn’t doing too badly under this government.
But, as ever in health policy, things aren’t quite that simple.
The sugar tax – more accurately two sugar levies – has rightly been welcomed by health service leaders, charities and obesity campaigners. It’s expected to be passed on to the consumer, meaning sugary drinks will cost more – about 8p for a can of cola. The idea is that this makes people less likely to buy those drinks, helping combat obesity and, in turn, health conditions such as diabetes and cancer. The government expects that, even if the cost isn’t passed on to the consumer, drinks manufacturers will reduce the sugar in their drinks to avoid paying the tax.
However, it isn’t a silver bullet. The effect on consumer and producer behaviour is hard to predict. And, in the context of a decimated public health budget, which would previously have been used to tackle obesity in local areas, it’s a bit like a tokenistic pretty plaster over an infected, neglected bedsore. The responsibility for public health sits with local authorities, who have suffered cuts up to 30% over the past 5 years. Public health alone has been cut by £200 million since the start of the parliament.
By the end of this parliament there’ll be no public health grants from central government at all. Instead, local councils will have use income from business rates. But these plans are in their infancy – so who knows how well they will work? Areas with the lowest income from business rates are likely to be those that are the most deprived – and therefore with the greatest need for strong public health services. The Budget announcement that business rates will be cut will make the squeeze on local government, and by extension public health, even worse.
For local authorities working to such tight budgets, it’s easy to see why public health services might not be the priority. For their spend they see little return – given that public health spending is intended to prevent expensive serious conditions from ever developing, the savings are most likely to accrue to the primary and secondary care budgets.
This is true for a number of areas: from stop-smoking services, which help prevent a whole host of tobacco-related illnesses, to social care. Poorly-equipped community care means that early intervention is far less likely, so patients aren’t seen until they are so acutely unwell that they need to be seen in hospital - which is far more expensive. But this isn’t just about economics – in terms of health outcomes and general wellbeing, the arguments for prevention and early intervention are strong.
This could be solved by radical change, such as integrating health and social care or pooling budgets, so that services can be commissioned based on outcomes across the patient pathway, not by siloed organisations responded to each individual issue the patient experiences.
Fortunately, this seems to be the direction of travel, albeit slowly, across the country, for example through NHS England’s bold New Models of Care programme. But new structures aren’t enough on their own. Pooling two under-resourced budgets doesn’t magically make them enough to provide good care to a local population. And in the absence of national change, most areas have to just make do with what they’ve got.
Some areas aim to tackle this by pooling budgets and integrating services - across public health, social care, primary care and secondary care. This is mentioned in several devolution proposals. The idea is that this will allow local areas to plan services that promote early intervention (therefore involving up-front investment, which isn't possible in the current public health climate). In other areas, this type of approach is already being taken more informally – some councils have asked GPs to fund public health services because they simply can’t afford it anymore. But in some areas, there’s nothing at all.
The Five Year Forward View says we need “radical upgrades in prevention and public health”. Tokenistic measures like a sugar tax, although welcome, just aren’t enough anymore.